Aon-SIA-11-11-10_IA-6-2011

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					                                                      Granite State Insurance Company
                                               Name of Insurance Company to which Application is made
                                                    (herein called the “insurer”, “company”, etc.)



Professional Liability Insurance                                                                    Administered by: Affinity Insurance Services
APPLICATION for “CLAIMS MADE AND REPORTED”                                                      159 East County Line Road • Hatboro, PA 19040-1218
Professional Liability (E&O) Policy                                                                   Phone 877-718-4655 Fax 877-443-9183
For Life Insurance Agents and Life Insurance Agencies                                                     www.aoninsuranceadvisors.com




  Instructions: Answer all questions. If the answer is none, state “none”. If an explanation is requested or space provided is
                insufficient, please attach a separate sheet to explain. Application must be completed in ink, signed and dated by the
                named applicant.

  Newly Licensed Agents: If you are newly licensed agent, please complete the entire application estimating your production and
                carriers for the upcoming year.

                  IF A POLICY IS ISSUED, IT WILL BE DONE ON A CLAIMS-MADE AND REPORTED BASIS.
                                     PLEASE REVIEW YOUR POLICY CAREFULLY.


  Name: ___________________________________________________________________________________________

  Agency: ______________________________________________ Phone: _(_______)__________-_________________

  Address: _____________________________________________ Fax: _(_______)____________-__________________

  City: __________________________________ State: ________ Zip: ________ E-mail ___________________________



                                      Part I - Proposed Insured (Applicant) Information

  1.       Are you the owner of the agency indicated above? .................................................................................................  Yes No
           If Yes, please indicate the number of agents housed in your agency including yourself:

  2.       Check the type of coverage you are applying for:

            Individual Agent Coverage (You are the “named insured” and coverage includes your non-producing clerical staff.)
                    If your gross commission income is in excess of $500,000 you must apply as an agency.

            Agency Coverage (Your agency is the “named insured” and coverage includes owners, officers and employees of the
                          named insured. Non-employee agents are not covered unless approved and added to the policy by
                          endorsement.)

  2a.      Your must answer Yes to the following questions in order to be eligible for agency coverage.

           1.         Has your agency been established for 3 or more years? ___ Yes ___ No
           2.         Does your agency produce more than 50% of its revenue from life, annuities, accident and health insurance
                      products? ___ Yes ___ No




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2b.          Please indicate the number of personnel in your agency. Designate each person under one category only.
                      Owners, officers, partners ................................................_______
                      Employee producers, brokers, agents .............................._______
                      Other Employees (including clerical) ................................_______
                      Total Staff (including clerical)                                           _______
                      Total Number of sub-agents/non-employee producers _______

3.           Are you or is anyone in your agency an employee of a/an insurance company, bank, savings and loan, credit union,
             automobile dealership or NASD broker dealer? ................................................................................................  Yes No

4.            Do you or does anyone in your agency have any of the following association memberships or professional designations?
                      NAILBA .............................................................................................….............  Yes No
                      NSSTA ............................................................................................................… Yes No
                      CPA ..........................................................................................….....................  Yes No
                      JD ................................................................................................…...................  Yes No
                      APA ................................................................................................…................  Yes No

5. List all states where licenses are held by you or anyone in your agency. ______ ______ ______ ______ ______ ______ ______

6. Please provide the following information for you or for members of your agency including all owners, officers, licensed employee
     producers. (Attach separate list if necessary):

                                                             # of                                                                    # of                                # of
Name                                    Life/ A&H                           Series 6         #of years           Series 7                             P&C
                                                            years                                                                   years                               years
                                       Yes No                 yrs.      Yes No                    yrs.      Yes No               yrs.       Yes No                 yrs.
                                       Yes No                 yrs.      Yes No                    yrs.      Yes No               yrs.       Yes No                 yrs.
                                       Yes No                 yrs.      Yes No                    yrs.      Yes No               yrs.       Yes No                 yrs.

     AGENCY applicants only, please complete this section
     A1. Is your agency operating as a corporation? ...........................................................................................…….................  Yes No
     A2. Date agency established? ____________________
     A3. Is coverage desired for sub-agents/non employee producers of the applicant for business placed only through the applicant?
                                                                                                                                                                    Yes No
          If so, list sub-agents who are to be covered for their acts in the sales and servicing of business written through your agency.
          Also indicate their Errors and Omissions coverage for the past three years and attach a separate sheet if

 Name                                             Annual Commission                    Name of Carrier                   Policy Period                 Policy Number (if
                                                   through applicant                                                                                       available)




     A4. Do you require evidence that all your sub-agents carry Errors and Omissions coverage each year? ....................…....  Yes No

     A5. Within the past five years, has there been a change in name, ownership, or a merger with/or a purchase of another agency?
                                                                                             Yes No If Yes, please attach full details.

     A6. Does the agency have additional business locations or is the agency doing business under a name other than listed on
     this application? ................................................................................................. Yes No If Yes, please attach full details.

     A7. Is your agency a member of a national producer group? ............................ Yes No                         If Yes, please attach an explanation.


                                                Part II - Professional Services and Revenue
Please provide the following information for you or your agency based on the previous year’s activities and revenue. If you are newly
licensed, please estimate activities and revenue for the next year and use the projected total revenue when providing the following
information.

1. Provide the gross annual income commission and fee revenue from life and health products for the following:

                                                               Commissions                                      Fee                                 Total Revenue
                                                                                               (Provide explanation of fees, if any)
         One Year Prior
         Estimated (next 12 months)
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2. Identify percentages of total revenue that was received last                  3. Identify by percentages your sources of total revenue:
   year as:
     a. Agent                                      ____%                              a. Personal production            _____%
     b. General Agent                              ____%
     c. Managing or Master General Agent           ____%                              b. From your sub-agents           _____%
     d. Brokerage General Agent                   ____%
     e. Other (explain) _____________________                                         c. From other agents              _____%
     ___________________________________ ____%
                                            TOTAL 100%                                                           TOTAL 100%

4. Identify percentages of total revenue that was earned last year from all professional activities:
a. Life                               ____% h. Products in a structured settlement              n. Insurance Consulting            ____%
b. Corporate Owned Life Insurance                  arrangement                          ____% o. Tax Consulting                    ____%
   Products (COLI)                    ____% i. Mutual Funds                             ____% p. Estate Planning                   ____%
c. Health                             ____% j. Other Financial Products                         q. RIA/Financial Planning on a fee
d. Multiple Employer Trusts/Multiple               (Do not include variable products or            basis                            ____%
   Employee Welfare Arrangements ____%             mutual funds)                        ____% r. Sale of Viatical Investments       ____%
e. Long Term Care                     ____% k. Property/Casualty Products               ____% s. Sale of Life Settlements           ____%
f. Self Insured Health Products      ____% l. Benefit/Pension Consulting                ____% t. Other (specify)______________ ____%
g. Annuities                         ____% m. Pension, Claims or                                            TOTAL (Items a through t) 100%
                                                   Third Party Administration           ____%


5. Do you or does anyone in your agency have the authority to perform activities which would customarily be performed by an
    insurance company, such as underwriting or claims administration?...........................................................................  Yes No

6. Regarding your office procedures, please answer the following questions:
    a. Is there a procedure for documenting client and carrier telephone conversations? .................................................  Yes No
    b. Are all applications, policies and riders checked for accuracy? ...............................................................................  Yes No
    c. Do you or does your agency have a system for client / carrier follow-up? ..,,,,.........................................................  Yes No

7. List the top five companies with which you place business (based upon total revenue):
     NAME OF COMPANY                                                 TYPE OF POLICY                                      ANNUAL COMMISSION
     ______________________________ ___                    ___________________________                       ______________________________
     ______________________________ ___                    ___________________________                       ______________________________
     ______________________________ ___                    ___________________________                       ______________________________
     ______________________________ ___                    ___________________________                       ______________________________
     ______________________________ ___                    ___________________________                       ______________________________

8. List all the other insurance companies with which you place insurance, attach separate sheet if necessary.

  ___________________________________________________________________________________________________
  ___________________________________________________________________________________________________
  ___________________________________________________________________________________________________




                                                          Part III - Coverage Desired

1. Please check the coverage limits and desired deductible:
          Coverage Limits                             Deductible                       Requested Effective Date
           $100,000/$300,000                          $ 1,000              ______/_________/_________
           $250,000/$500,000                          $ 2,500
           $500,000/$1,000,000                        $ 5,000
           $1,000,000/$2,000,000*                     $ 7,500
           $2,000,000/$2,000,000                      $10,000
           $3,000,000/$3,000,000**                    $__________ Up to $25,000 - AGENCIES only may qualify.
           $4,000,000/$4,000,000**
           $5,000,000/$5,000,000**

          Note: Limits and deductible selected are subject to underwriting approval.
          * The highest limit available in the states of Alabama and Texas is $1,000,000/$2,000,000.
          ** These higher limits are available for agency coverage only.


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2. Is coverage desired for the sale of mutual funds, covered financial products or property & casualty products? ...............  Yes No
     (Financial products coverage includes mutual funds, stocks, bonds, unit investment trusts and limited partnership. If P&C coverage
     is desired, a separate application is needed.)

3. If Yes, list persons who are applying for Supplemental Coverage (available to agents listed in Part I, Question 6 only).
      Agent                                    Broker/Dealer                      Mutual Funds       Financial Products                P&C
      _____________________________            _________________________           Yes No           Yes No                          Yes No
      _____________________________            _________________________           Yes No           Yes No                          Yes No
      _____________________________            _________________________           Yes No           Yes No                          Yes No
      _____________________________            _________________________           Yes No           Yes No                          Yes No

4. Do you or does anyone in your agency have ownership interest in a broker/dealer organization? ............................. .......  Yes No



                                  Part IV - Current Coverage and Claims/Loss History
1. Indicate your Errors & Omissions coverage for the past three years and attach a copy of your last Declarations Page. If you are
     applying for agency coverage, indicate Your Agency’s Errors and Omissions coverage for the past three years and attach a copy of
     your last Declarations Page. If no agency coverage previously existed, please list the Errors and Omissions coverage for each
     agent under their individual Errors and Omissions policies. If none, state “none”.


                                                                                          Policy Term                    Did Coverage include all
                Name of Carrier                         Limits
                                                                                Effective Date Expiration Date            Products & Carriers?
                                                                                                                               Yes No
                                                                                                                               Yes No
                                                                                                                               Yes No


2. Have you or any past or present owner, officer, partner, employee or solicitor been the subject of disciplinary action
     by any insurance or other regulatory authority? If Yes, attach an explanation. ..............................………...................  Yes No
3. Has any policy or application for Errors and Omissions insurance on behalf of the applicant or any of its past or
     present owners, officers, partners, employees or solicitors, or to the knowledge of the applicant, on behalf of its
     predecessors in business, ever been declined, canceled or renewal refused within the past 10 years? ……… .........  Yes No
     If Yes, attach an explanation. (Not applicable if domiciled in Missouri)
4. Have any Errors and Omissions claims been made against the applicant or any of its past or present owners,
     officers, partners, employees or solicitors, or to the knowledge of the applicant, on behalf of its predecessors
     in business, within the past 10 years? ………………………………………………………………………………… ….  Yes No
     If Yes, attach an explanation stating nature of claim, date of claim, loss payments and disposition, E&O carrier
     handling claim, etc.
5. Are there any circumstances which may result in Errors and Omissions claims being made against the applicant,
     past or present owners, officers, partners, employees or solicitors, or its predecessor in business? ...........................  Yes No
     If Yes, attach an explanation.
6. In the last five years have any agent/agency contracts you have held with any carrier been canceled for cause? .........  Yes No
     If Yes, attach an explanation.

                                                             FRAUD WARNINGS

NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PE RSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING
ANY M ATERIALLY FALSE IN FORMATION OR, C ONCEALS, F OR TH E P URPOSE OF MISLEADING, I NFORMATION
CONCERNING ANY F ACT MATER IAL THERE TO, COMMITS A FR AUDULENT ACT, WHICH I S A C RIME A ND MAY
SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FA LSE
OR FRA UDULENT CLAI M FO R PAY MENT OF A     LOSS OR BEN EFIT, OR KNOW INGLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FO R IN SURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FIN ES
AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INC OMPLETE, OR
MISLEADING FA CTS O R I NFORMATION TO AN IN SURANCE CO MPANY FO R TH E PU RPOSE OF DEFRA UDING OR
ATTEMPTING TO DEFRAUD T HE C OMPANY. PENALTIES MAY INCL UDE IMPR ISONMENT, F INES, DENIAL OF
INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR A GENT OF AN INSURANCE COMPANY WHO
86757 (06/10)                                                                                                                              4
KNOWINGLY PROV IDES FA LSE, IN COMPLETE, OR MI SLEADING FA CTS OR I NFORMATION TO A PO LICYHOLDER
OR CLAIMANT FOR THE PURPOSE OF DE FRAUDING OR ATTEMPTING TO DE FRAUD T HE P OLICYHOLDER OR
CLAIMANT WITH REGARD TO A SE TTLEMENT OR AWAR D PAYABLE FROM INSUR ANCE PR OCEEDS S HALL BE
REPORTED TO T HE C OLORADO DIVISION O F I NSURANCE WITHIN THE DE PARTMENT OF REGULATOR Y
AUTHORITIES

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE F ALSE OR
MISLEADING INFORMATION TO AN INSURER FOR THE P URPOSE OF DEFRAUDING THE INSURER OR AN Y OTHER
PERSON. P ENALTIES I NCLUDE IM PRISONMENT AN D/OR FIN ES. I N AD DITION, AN I NSURER M AY DE NY
INSURANCE BENEFI TS I F FALS E IN FORMATION MATERIALLY RELAT ED TO A CLAIM WAS PR OVIDED BY T HE
APPLICANT.

NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD,
OR DECE IVE AN Y I NSURER FILES A STA TEMENT OF CL AIM OR AN A PPLICATION CONT AINING A NY F ALSE,
INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.

NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KN OWINGLY AND WITH IN TENT TO DEFRAUD AN Y
INSURANCE COM PANY OR OTH ER PERSON FILES AN APPLICATION FOR I NSURANCE CONT AINING AN Y
MATERIALLY FALSE INF ORMATION, OR CONCEALS FOR THE P URPOSE OF M ISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

NOTICE TO LOUISIANA APPLICANTS: ANY PERSON W HO K NOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM F OR PAYM ENT OF A LOSS OR BENEF IT OR KNOWINGLY PRESENTS F ALSE I NFORMATION IN AN
APPLICATION FOR I NSURANCE IS GUILTY OF A CRIME AND MAY BE S UBJECT TO FI NES AND CONFINEMENT IN
PRISON.

NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PR OVIDE FAL SE, INCOMPLETE OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY.
PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE
OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY
PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD
OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.

NOTICE TO NEW JERSEY APPLICANTS: AN Y PERSON W HO INCLUDES ANY FALSE OR MISLEADING
INFORMATION ON AN A PPLICATION FO R AN I NSURANCE PO LICY I S SU BJECT TO CRI MINAL AND CI VIL
PENALTIES.

NOTICE TO NEW YORK APPLICANTS: A NY PERSON W HO KNOWINGLY A ND W ITH I NTENT TO D EFRAUD ANY
INSURANCE COMPANY OR OTHER PE RSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CL AIM
CONTAINING ANY M ATERIALLY F ALSE I NFORMATION, OR CONCE ALS F OR TH E PURPOSE O F M ISLEADING,
INFORMATION CO NCERNING ANY FACT M ATERIAL T HERETO, COM MITS A FRA UDULENT IN SURANCE A CT,
WHICH IS A CRIME, AND S HALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED F IVE THOUS AND
DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

NOTICE TO OHIO APPLICANTS: A NY PER SON WH O, WITH IN TENT T O DEFR AUD OR KN OWING T HAT H E IS
FACILITATING A FR AUD AG AINST AN I NSURER, SUBM ITS AN APP LICATION OR FILE S A CLAIM CONT AINING A
FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON W HO K NOWINGLY, AN D W ITH I NTENT TO
INJURE, DEFRAUD OR DECEIVE A NY I NSURER, M AKES A NY CLA IM F OR TH E PR OCEEDS OF AN INSURANCE
POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-
1-10, 36 §3613.1).

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     NOTICE TO OREG ON APPLICANTS: ANY PERSON WHO K NOWINGLY AND WITH INTENT TO DEFRA UD A NY
     INSURANCE COMPANY OR OTHE R PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF
     CLAIM CO NTAINING A NY MATERI ALLY FALSE INFO RMATION O R, CO NCEALS, FOR THE PURPOSE OF
     MISLEADING, INFO RMATION CONCERNING A NY FACT MA TERIAL T HERETO, COMMITS A FRA UDULENT A CT,
     WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES

     NOTICE TO PENNSYLVANIA APPLICANTS: AN Y PERSON WH O K NOWINGLY AN D WIT H I NTENT TO DEFRAUD
     ANY INSURANCE C OMPANY OR OT HER PERS ON F ILES AN APPLICATION F OR I NSURANCE OR STATEMENT OF
     CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING,
     INFORMATION CO NCERNING ANY FACT M ATERIAL TH ERETO COM MITS A FR AUDULENT I NSURANCE A CT,
     WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

     NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: I T IS A CRI ME TO K NOWINGLY P ROVIDE F ALSE,
     INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING
     THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.




                                                       Part V - Authorization and Declaration
     All claims will be excluded that result from any circumstances or situations known prior to the inception of coverage being applied for
     that could reasonably be expected to result in a claim. Applicant hereby represents that the statements and answers to questions made
     above and attachments hereto are true and applicant has not omitted or misrepresented any information. Applicant understands and
     agrees that the completion of this application does not bind the insurance carrier to issue an insurance policy. Further, the applicant
     understands and agrees that she or he is obligated to report any changes in the information provided in this application that occur after
     the date of the application.

     Signature: ______________________________________________________________ Date: _____________________________
                                        (Principal, Partner, or Officer of Applicant)

     Title: ______________________________________________________________________________________________________________

     Producer/Agent Signature:________________________________________________________ __ Date: __________________________


 Producer/Agent Name:_______________________________________________________________________________________




1.          Is every question answered? ____ Yes ___No
2.          Have you attached copies of your errors and omission certificates? ____ Yes ___No
3.          Have you provided an explanation of the questions where required? ____ Yes ___No
4.          Have you signed and dated the application? ____ Yes ___No
5.          Please fax the completed application to 877-443-9183 or mail to Affinity Insurance Services
            Attn: Aon Solutions for Insurance Advisors 159 East County Line Road Hatboro, PA 19040-1218

     86757 (06/10)                                                                                                                   6

				
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